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MMWR 35(10);152-5

Publication date: 03/14/1986

Table of Contents

Article

BACKGROUND

Human T-lymphotropic virus type III/lymphadenopathy-associated virus
(HTLV-III/LAV), the virus that causes acquired immunodeficiency syndrome
(AIDS), is transmitted through sexual contact, parenteral exposure to
infected blood or blood components, and perinatally from mother to fetus or
neonate. In the United States, over 73% of adult AIDS patients are
homosexual or bisexual men; 11% of these males also had a history of
intravenous (IV) drug abuse. Seventeen percent of all adult AIDS patients
were heterosexual men or women who abused IV drugs (1,2). The prevalence of
HTLV-III/LAV antibody is high in certain risk groups in the United States
(3,4).

Since a large proportion of seropositive asymptomatic persons have been
shown to be viremic (5), all seropositive individuals, whether symptomatic or
not, must be presumed capable of transmitting this infection. A repeatedly
reactive serologic test for HTLV-III/LAV has important medical, as well as
public health, implications for the individual and his/her health-care
provider. The purpose of these recommendations is to suggest ways to
facilitate identification of seropositive asymptomatic persons, both for
medical evaluation and for counseling to prevent transmission.
Previous U.S. Public Health Service recommendations pertaining to
sexual, IV drug abuse, and perinatal transmission of HTLV-III/LAV have been
published (6-8). Reduction of sexual and IV transmission of HTLV-III/LAV
should be enhanced by using available serologic tests to give asymptomatic,
infected individuals in high-risk groups the opportunity to know their status
so they can take appropriate steps to prevent the further transmission of
this virus.

Since the objective of these additional recommendations is to help
interrupt transmission by encouraging testing and counseling among persons in
high-risk groups, careful attention must be paid to maintaining
confidentiality and to protecting records from any unauthorized disclosure.
The ability of health departments to assure confidentiality -- and the public
confidence in that ability -- are crucial to efforts to increase the number
of persons requesting such testing and counseling. Without appropriate
confidentiality protection, anonymous testing should be considered. Persons
tested anonymously would still be offered medical evaluation and counseling.

PERSONS AT INCREASED RISK OF HTLV-III/LAV INFECTION

Persons at increased risk of HTLV-III/LAV infection include: (1)
homosexual and bisexual men; (2) present or past IV drug abusers; (3) persons
with clinical or laboratory evidence of infection, such as those with signs
or symptoms compatible with AIDS or AIDS-related complex (ARC); (4) persons
born in countries where heterosexual transmission is thought to play a major
role *; (5) male or female prostitutes and their sex partners; (6) sex
partners of infected persons or persons at increased risk; (7) all persons
with hemophilia who have received clotting-factor products; and (8) newborn
infants of high-risk or infected mothers.

RECOMMENDATIONS

Community health education programs should be aimed at members of high-risk groups to: (a) increase knowledge of AIDS; (b) facilitate
behavioral changes to reduce risks of HTLV-III/LAV infection; and (c)
encourage voluntary testing and counseling.

Counseling and voluntary serologic testing for HTLV-III/LAV should be
routinely offered to all persons at increased risk when they present to
health-care settings. Such facilities include, but are not limited to,
sexually transmitted disease clinics, clinics for treating parenteral
drug abusers, and clinics for examining prostitutes.
a. Persons with a repeatedly reactive test result (see section on Test
Interpretation) should receive a thorough medical evaluation, which
may include history, physical examination, and appropriate
laboratory studies.
b. High-risk persons with a negative test result should be counseled
to reduce their risk of becoming infected by:
(1) Reducing the number of sex partners. A stable, mutually
monogamous relationship with an uninfected person eliminates
any new risk of sexually transmitted HTLV-III/LAV infection.
(2) Protecting themselves during sexual activity with any possibly
infected person by taking appropriate precautions to prevent
contact with the person's blood, semen, urine, feces, saliva,
cervical secretions, or vaginal secretions. Although the
efficacy of condoms in preventing infections with HTLV-III/LAV
is still under study, consistent use of condoms should reduce
transmission of HTLV-III/LAV by preventing exposure to semen
and infected lymphocytes (9,10).
(3) For IV drug abusers, enrolling or continuing in programs to
eliminate abuse of IV substances. Needles, other apparatus,
and drugs must never be shared.
c. Infected persons should be counseled to prevent the further
transmission of HTLV-III/LAV by:
(1) Informing prospective sex partners of his/her infection with
HTLV-III/LAV, so they can take appropriate precautions.
Clearly, abstention from sexual activity with another person
is one option that would eliminate any risk of sexually
transmitted HTLV-III/LAV infection.
(2) Protecting a partner during any sexual activity by taking
appropriate precautions to prevent that individual from coming
into contact with the infected person's blood, semen, urine,
feces, saliva, cervical secretions, or vaginal secretions.
Although the efficacy of using condoms to prevent infections
with HTLV-III/LAV is still under study, consistent use of
condoms should reduce transmission of HTLV-III/LAV by
preventing exposure to semen and infected lymphocytes (9,10).
(3) Informing previous sex partners and any persons with whom
needles were shared of their potential exposure to HTLV-
III/LAV and encouraging them to seek counseling/testing.
(4) For IV drug abusers, enrolling or continuing in programs to
eliminate abuse of IV substances. Needles, other apparatus,
and drugs must never be shared.
(5) Not sharing toothbrushes, razors, or other items that could
become contaminated with blood.
(6) Refraining from donating blood, plasma, body organs, other
tissue, or semen.
(7) Avoiding pregnancy until more is known about the risks of
transmitting HTLV-III/LAV from mother to fetus or newborn (8).
(8) Cleaning and disinfecting surfaces on which blood or other
body fluids have spilled, in accordance with previous
recommendations (2).
(9) Informing physicians, dentists, and other appropriate health
professionals of his/her antibody status when seeking medical
care so that the patient can be appropriately evaluated.

Infected patients should be encouraged to refer sex partners or persons
with whom they have shared needles to their health-care provider for
evaluation and/or testing. If patients prefer, trained health
department professionals should be made available to assist in notifying
their partners and counseling them regarding evaluation and/or testing.

Persons with a negative test result should be counseled regarding their
need for continued evaluation to monitor their infection status if they
continue high-risk behavior (8).

State and local health officials should evaluate the implications of
requiring the reporting of repeatedly reactive HTLV-III/LAV antibody
test results to the state health department.

State or local action is appropriate on public health grounds to
regulate or close establishments where there is evidence that they
facilitate high-risk behaviors, such as anonymous sexual contacts and/or
intercourse with multiple partners or IV drug abuse (e.g., bathhouses,
houses of prostitution, "shooting galleries").

TEST INTERPRETATION

Commercially available tests to detect antibody to HTLV-III/LAV are
enzyme-linked immunosorbant assays (ELISAs) using antigens derived from
disrupted HTLV-III/LAV. When the ELISA is reactive on initial testing, it is
standard procedure to repeat the test on the same specimen. Repeatedly
reactive tests are highly sensitive and specific for HTLV-III/LAV antibody.
However, since falsely positive tests occur, and the implications of a
positive test are serious, additional more specific tests (e.g., Western
blot, immunofluorescent assay, etc.) are recommended following repeatedly
reactive ELISA results, especially in low-prevalence populations. If
additional more specific test results are not readily available, persons in
high-risk groups with strong repeatedly reactive ELISA results can be
counseled before any additional test results are received regarding their
probable infection status, their need for medical follow-up, and ways to
reduce further transmission of HTLV-III/LAV.

OTHER CONSIDERATIONS

State or local policies governing informing and counseling sex partners
and those who share needles with persons who are HTLV-III/LAV-antibody
positive will vary, depending on state and local statutes that authorize such
actions. Accomplishing the objective of interrupting transmission by
encouraging testing and counseling among persons in high-risk groups will
depend heavily on health officials paying careful attention to maintaining
confidentiality and protecting records from unauthorized disclosure.
The public health effectiveness of various approaches to counseling,
sex-partner referral, and laboratory testing will require careful monitoring.
The feasibility and efficacy of each of these measures should be evaluated by
state and local health departments to best utilize available resources.

Developed by Center for Prevention Svcs and Center for Infectious Diseases,
CDC, in consultation with persons from numerous other organizations and
groups.

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